Form: Smart Smiles Savings Program

Patient Information

The following is a description of the Smart Smiles Savings Program available to you and your family through Farmington Family Dentistry. This description describes the program and your rights under the program, and if you choose to enroll it is your contract with Farmington Family Dentistry. You should read this carefully. If you have any questions about this description, please call Farmington Family Dentistry at 860.677.1316.

                The full name of the plan: Smart Smiles Savings Program

                Annual Fee: $425

                Our website is: www.farmingtonctsmiles.com

                Our email address is: [email protected]

This is a discount dental plan. The Smart Smiles Savings Programs is not an insurance product. This plan cannot be used in conjunction with any dental insurance plan, in office discounts, (such as senior discounts) or financing plan (such as CareCredit). By paying an annual enrollment fee to the Smart Smiles Savings Program, you will be entitled to receive the following dental services during each enrollment period:

Preventative Services included in the Smart Smiles Savings Program:

  • 2 periodic examinations
  • 2 cleanings (non-periodontal based)
  • 2 oral cancer screenings
  • Fluoride treatments (as deemed necessary by the doctors)
  • Any necessary radiographs (as deemed necessary by the doctors)
  • 1 Emergency Visit

Services Provided at a Discounted Fee in the Smart Smiles Savings Program:

  • 20% off additional cleanings, sealants, fillings, core buildups, extractions, root canals and         

periodontal therapy

  • 15% off crowns, veneers, dentures, partial dentures and implant restorations
  • $500 off Invisalign treatments

All services provided at the discounted fees will be due at the time of service.

All services are provided by scheduled appointments only.

The Smart Smiles Savings Programs does not include:

  • Treatment, which is the sole opinion of the doctor, lies outside of the realm of their capabilities
  • Fees when referred to a specialist for care
  • Hospitalizations or hospital charges of any kind
  • Cost of dental care which are covered under medical insurance
  • Services required to repair dental injuries covered under Workman’s Compensation

Once you have read through this description, please sign and date on the last page to enroll in this program. You may either send the completed form with payment to Farmington Family Dentistry or give it to a member of the front desk staff along with your payment for the one-time processing fee of $50 and the initial annual enrollment fee. Annual membership fees, can be made by cash, check, debit or credit card and they are NON-REFUNDABLE.

Once your Enrollment Form and fees are received and processed, you will receive an identification card. Eligibility begins when Farmington Family Dentistry receives your processing fee and annual fee. You must present your identification card at the office before you receive treatment. If you are applying for the Smart Smiles Savings Program in the office, once payment is received, discounts could be immediately applied.

Your right to receive services will continue for one year from the time Farmington Family Dentistry receives your initial enrollment fee. The termination date will appear on your identification card and will end at midnight on that date. No refunds of the annual enrollment fee will be issued at any time if the participant decides not to utilize the dental savings plan.

Your right to receive services at the discounted fees described in this plan will end at the expiration of your one-year term unless you re-enroll before the expiration date to avoid paying an additional processing fee. Upon termination, Farmington Family Dentistry will complete all procedures started before termination.

You can renew your right to receive discounted fee services for an additional year by paying an annual re-enrollment fee to Farmington Family Dentistry before your initial eligibility terminates. The annual re-enrollment fee maybe different from the initial annual enrollment fees. You will be notified what the applicable fee is on your renewal notice. Upon re-enrollment, you will receive a new identification card.

The same procedure will be used to re-enroll for succeeding years. Other than payment of the required fee, there are no conditions or restrictions on your right to re-enroll.

You can terminate your eligibility after any one-year period simply by choosing no to re-enroll. Farmington Family Dentistry cannot cancel your enrollment or refuse to permit you from re-enrolling after any one-year period ends unless you have engaged in fraud in using this plan.

Sign Form

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.